Surveillance of child development in a daycare center: a study on the maternal perspective

Abstract

Objective  To understand the maternal perception about the surveillance of the development of children under three years old who attend a daycare center.

Method  A qualitative study with nine mothers of children under the age of three, enrolled in a daycare center in João Pessoa-PB, linked to a Family Health Unit. Data was collected through semi-structured interviews and subjected to thematic analysis.

Results  The monitoring of the development of children attending a daycare center is weakened, since most mothers do not take the child to childcare in order to monitor growth and development, and the inclusion of health professionals in the daycare center is still limited. However, the mothers recognize the daycare center as an ideal setting for the promotion of child development and the importance of health professionals in this setting.

Conclusion and implications for the practice  Joint actions of the daycare center with the Family Health Unit are necessary for comprehensive care and surveillance of child development.

Keywords:  Child Health; Growth and Development; Family Health Strategy; Child Daycare Centers; Mothers

Resumo

Objetivo  Compreender a percepção materna acerca da vigilância do desenvolvimento de crianças menores de três anos que frequentam creche.

Método  Estudo qualitativo com nove mães de crianças menores de três anos, matriculadas em uma creche do município de João Pessoa-PB, vinculada a uma Unidade de Saúde da Família. Os dados foram coletados por meio de entrevistas semiestruturadas e submetidos à análise temática.

Resultados  A vigilância do desenvolvimento de crianças que frequentam creche encontra-se fragilizada, visto que a maioria das mães não costumam levar a criança para a unidade de saúde, para o acompanhamento do crescimento e desenvolvimento, e a inserção dos profissionais de saúde na creche ainda é limitada. Entretanto, as mães reconhecem a creche como cenário ideal para a promoção do desenvolvimento infantil e a importância da atuação dos profissionais de saúde nesse cenário.

Conclusão e implicações para prática  São necessárias ações conjuntas da creche com a Unidade de Saúde da Família para a atenção integral e vigilância do desenvolvimento infantil.

Palavras-chave:  Saúde da Criança; Crescimento e Desenvolvimento; Estratégia Saúde da Família; Creches; Mães

Resumen

Objetivo  Comprender la percepción materna sobre la vigilancia del desarrollo de los niños menores de tres años que asisten a la guardería.

Metodo  Estudio cualitativo con nueve madres de niños menores de tres años, inscriptos en una guardería de la ciudad de João Pessoa-PB, vinculada a una Unidad de Salud de la Familia. Los datos se recopilaron a través de entrevistas semiestructuradas y se sometieron a análisis temático.

Resultados  La vigilancia del desarrollo de los niños que asisten a la guardería se debilita, ya que la mayoría de las madres no llevan al niño a la guardería, para monitorear el crecimiento y desarrollo, y la inclusión de profesionales de la salud en la guardería aún es limitada. Sin embargo, las madres reconocen la guardería como un escenario ideal para la promoción del desarrollo infantil y la importancia del desempeño de los profesionales de la salud en este ámbito.

Conclusión e implicaciones para la práctica  Son necesarias acciones conjuntas de la guardería y la Unidad de Salud de la Familia para lograr la atención integral y vigilancia del desarrollo infantil.

Palabras clave:  Salud del Niño; Crecimiento y Desarrollo; Estrategia de Salud Familiar; Jardines Infantiles; Madres

INTRODUCTION

Scientific and technological advances, changes in care models and concern for quality of life and human rights have led to significant changes in child health care, with the aim of preventing possible health problems and reducing child mortality. Thus, health care in childhood has reached important spaces in the public policies, with proposals for actions in different care contexts, such as monitoring development, especially in early childhood, which corresponds to the period from zero to six years old.¹

In this phase, there are intense changes in the child's physical and neuropsychomotor development, requiring continuous care and guided by regular monitoring of growth and development, in order to previously identify possible health problems.² Thus, the first years are essential for Child Development Surveillance (CDS).

It is estimated that, in the world, 200 million children under the age of five are at risk of not reaching their development potential.³ Thus, the importance of CDS actions that seek to identify possible changes in development, to stimulate and to direct appropriate care to the child through professional assessment is emphasized.² Therefore, child care is fundamental, especially during the first three years of life, considering that it represents the age group with the greatest brain plasticity and the possibility of reversing delays in a timely manner.⁴

In this context, we highlight the Reference Centers in Early Childhood Education (Centros de Referência em Educação Infantil, CREIs), also known as daycare centers, places where there is concentration of children in important age groups to carry out growth and development surveillance, becoming fundamental environments for child care. These spaces allow for the identification of risk factors for developmental delays; among them, socioeconomic level, housing, schooling of parents/caregivers, and child vulnerability.⁵

The expressive growth in the insertion of children in early childhood education centers is evident,⁶ with an increase of 84.6% in the number of enrollments in Brazilian daycare centers in the last eight years,⁷ following the worldwide trend that had a growth of 64.0% in enrollments between 1999 and 2012.⁶

However, in order to be a favorable environment for children's development, daycare centers must offer quality services capable of promoting CDS. According to a study,^8,the quality of the nursery environment, that is, the physical structure, the human resources available and the care provided to the child, added to other extrinsic factors, such as greater maternal education and longer time spent in the nursery, positively influence motor development of the children who attend this educational environment.

In view of the relevance CREIs, the Law of the Guidelines and Bases of National Education emphasizes the role of the teachers involved in early childhood education, the first stage of basic education, in order to promote the integral development of children up to five years old in their physical, psychological, intellectual and social aspects, complementing the action of the family and the community.⁹ Thus, daycare centers or equivalent entities become privileged settings for the surveillance of child development.

With this in mind, the Ministries of Health and Education implemented the Health at School Program (Programa Saúde na Escola, PSE) in 2007, and one of its axes concerns clinical and psychosocial assessment, in which, among others, anthropometric assessment is contemplated, as well as updating of the vaccination calendar, ophthalmological, auditory, nutritional and oral health evaluation.¹⁰ It is noteworthy that these actions are also part of the routine of childcare in primary care. Therefore, understanding that the PSE represents the link between the Basic Health Unit (BHU) and the basic education schools, it is fundamental that the health actions proposed in the program are also carried out in the CREIs.

Childcare consultations in primary care are carried out by physicians and nurses.¹¹ The performance of these professionals in the face of the needs of the child who is inserted in the daycare center, has great value for the longitudinality of the child's care. Despite this, it is perceived that these professionals still have limited performance in the CREIs, and this can be one of the reasons for failures in monitoring the growth and development of children in early childhood,¹² especially those who attend daycare centers.

In addition to that, in the practice it is perceived that the mothers do not usually take their children who attend the CREIs to the childcare consultation, corroborating a study that highlights that the failure to attend childcare consultations in the Family Health Strategy (FHS) is a problem among children enrolled in daycare centers, which can compromise the monitoring of their development.⁵

In addition, the role of the mothers in promoting healthy child development is highlighted, given that the child's interaction with them shapes their experiences. The child interacts with the family and the community, including the daycare center. Thus, responsive care at home and in the daycare center and enriching and protective interactions provide an ideal environment for their development and protect the child from the negative effects of adversity.¹³

Family members and caregivers also play a fundamental role for CDS in the daycare center, as long as, when needed, they understand and support the work of the daycare and health professionals in this educational setting. Therefore, the participation of the family becomes indispensable for good child development.¹⁴

Given the above, this study is justified by the importance of investigating the existence of child development surveillance by health professionals in daycare centers and its meaning for the mothers, in view of the relevance of monitoring the child, both by daycare and health professionals. For this, the following questions emerged: What is the maternal perception regarding the growth and development of the child under three years old who attends a daycare center? What is the importance of the daycare center and the Family Health Unit (FHU) for child development? In order to answer the questions, this study aims to understand the maternal perception about development surveillance of children under three years old who attend a daycare center.

METHOD

This is a descriptive-exploratory study with a qualitative approach, developed in a Reference Center in Child Education, an educational institution focused on early childhood, in the municipality of João Pessoa-PB which participated in the Health at School Program and was linked to a Family Health Unit. The municipality's early childhood education network is made up of 90 CREIs linked to the Education Secretariat.¹⁵

The research participants were mothers of children who met the following inclusion criteria: being a mother of a child under the age of three and enrolled in a daycare center. Mothers with communication difficulties and those under 18 years old were excluded.

To carry out data collection, contact was made with the Municipal Education and Culture Secretariat of the aforementioned municipality in order to authorize the research. After that, the researcher contacted the CREI coordination, in order to explain the research in detail and request their support to facilitate communication with the children's mothers. Data collection took place shortly after the CREI coordination authorization and the mothers' formal acceptance and authorization, by signing the Free and Informed Consent Form (FICF).

The data were collected through semi-structured interviews, which were recorded on digital media and later transcribed in full. The end of data collection was due to saturation.

A semi-structured interview script was used, containing the following guiding questions: i) Is your child's growth and development monitored? Where is the monitoring of your child's growth and development carried out? ii) What is the importance of monitoring growth and development? Talk a little about it. iii) What is your perception of your child's development monitored by the daycare center? iiii) What is the role of daycare in your child's development? And the role of the health unit?

Data analysis followed the steps of the thematic analysis proposed by Minayo;¹⁶ therefore, initially, the organization of the data covering the set of material collected in the interviews was conducted. Then, we transcribed the recorded interviews to proceed with the first organization of the reports in a certain order, already starting a classification. In this phase, the horizontal map of the material was drawn. Subsequently, in light of the theoretical framework, as well as of the proposed objectives, we carried out an exhaustive and repeated reading of the texts, making an interrogative relation with them in order to apprehend the relevant structures. Such procedure allowed us to develop a classification through cross-sectional reading. Then, based on the relevant structures, we reduced the classification, regrouping the most relevant themes for the final analysis.

To guarantee the anonymity of the participants, the excerpts from the statements were identified with the letter M referring to mother, followed by an ordering of the numbers that represents the sequence of the interviews.

This research was conducted according to the guidelines contained in Resolution No. 466/2012¹⁷ and is linked to the project entitled “Child development surveillance: paths and perspectives for Nursing”, approved by the Ethics and Research Committee of the Health Sciences Center of the Federal University of Paraíba, under opinion No. 2,189,497, CAAE: 02584212.3.0000.5188.

RESULTS

The study included the participation of nine mothers, aged between 22 and 42 years old. With regard to schooling, five mothers did not finish high school, two finished high school, and two had higher education. In terms of occupation, five were housewives, three were self-employed and one was a student. Most of the participants had a stable marital relationship or were married. Regarding monthly family income, seven participants stated that they had an income equal to or less than one minimum wage.

Based on the mothers' reports, it was possible to construct two thematic categories: Fragility in the surveillance of the development of children attending a daycare center; The daycare center as an ideal setting for the promotion of child development.

Fragility in the surveillance of the development of children attending a daycare center

The monitoring of the child by health professionals since birth is fundamental to monitor possible health problems, prevent diseases and, above all, carry out surveillance of child growth and development However, with the analyzed reports, it is perceived that few mothers claimed to take the child to childcare consultations:

The doctor monitors her (...) Her childcare used to be at the UH [University Hospital], but as it is far away and I don't always have a bus ticket, I do it here at the FHP [Family Health Program]. (M2)

She's monitored by the nurse at the health center, to weigh her, to know how her development is going. I take her there every six months because they said that as she's older, three years old, then it is no longer routine to take her every month. (M4)

Some mothers reported the absence of a physician at the Family Health Unit (FHU) as a reason for not taking the child to monitor growth and development in the childcare consultation and for the child not to miss the daycare center, while others just stated that they stopped taking the child to the FHU, but without pointing out the reason:

At the moment I'm not taking him to the Health Unit because there is no doctor in my area, so I stopped going. (M1)

He was monitored only when he was a baby, until one year old, by a health professional. Every month we kept doing it, but after a year no more. (M3)

So, I only went to the health center when he was born, now I'm not going anymore because he stays here at the daycare center during the day. (M6)

When she was a baby, she went every month, up to one year and six months old. When she turned two, I still went, but now I'm not going anymore. (M7)

No, he has already gone to the clinic, but there's no pediatrician, so when I see anything, any problem, we go to the doctor (...) No, I don't remember doing any monitoring with her [the child]. (M8)

Another aspect that emerged in the mothers' statements is that some of them only seek FHU services in cases of illness in the child or to assess the anthropometric data required by an assistance program, such as the Bolsa Família Program:

The last time I went there, which was for weighing due to Bolsa Família, they said that they still didn't have a doctor, told me to go tomorrow and maybe they would have a doctor. (M1)

He doesn't go to the consultation anymore, he only goes when he needs to. When he's sick I take him to the doctor, you know? (M6)

When I see anything, any problem, we go to the doctor at the general clinic, through the SUS. When she's sick, I go to the doctor (...), there's no pediatrician to keep the monitoring. (M8)

I only take her when she's ill, but there's no fixed monitoring, only when she was a baby. (M9)

However, although the study participants are not in the habit of taking the children to childcare, the following reports demonstrate that they recognize the importance of this monitoring routine:

It is necessary because the child can be three years old, be born underweight, and going to monitoring we have all the instructions that he's at the right weight, that he's eating. (M4)

It's good to know if the child is doing well, right?! If there's any health problem. (M7)

It is important to know the child's development, if he's developing well, if he's growing well, if he's at the ideal height and weight. (M9)

[it is important] for his development, both physical and emotional, it was very important. To make the measurements, the head and everything, his weight, how the diet was, so it was very important for his growth, to know if everything was fine with him. (M3)

In addition to the health unit, the daycare center was another scenario mentioned for carrying out health actions in conjunction with the FHU, according to the following reports:

There was a meeting in which the health professionals came to see him, the dentist (...). (M1)

Sometimes she comes home saying she had brushed her teeth at the school. (M7)

Here [daycare center] they always come, the nurses at the unit come to know about the booklets, the vaccine, everything... I think that every month they come, every month they are there because there's always a child with a vaccine to take every month. And I take her once a month. (M5)

The daycare center as an ideal setting for the promotion of child development

The insertion of children in the daycare center brings several advances in their cognitive, physical, emotional and behavioral development, and it is not only marked by the maternal need to enter the labor market, but the mothers also recognize that the institution is fundamental for the child to acquire new skills and new social behaviors, reinforcing the daycare center's positive influence on their children's development:

She learned to count, to paint a little, to eat on her own. (M7)

I think the importance of the daycare center is precisely that, his development as a person too. In addition to our home, here at school he also develops his personal side, communication with classmates, with people, so I think it's extremely important. (M3)

There's a difference in the child's behavior after she started coming to the daycare center. She has learned a lot more things, how to deal with other children too, (...) here she learns that she has to share the toys, interact with other children, she has developed a lot. (M4)

She's much better. Before, she didn't speak much and now she talks too much, she's learning the things she comes home telling me, she learns a lot. The development was like that, she didn't talk to anyone much and now she's more relaxed, she eats what she didn't eat at home, her diet improved a lot, she eats alone, she learned to pee and she doesn't use diapers anymore, everything here [in the daycare center]. (M5)

The mothers perceive the daycare center as a potential setting for child development. In addition to that, they consider the home, together with the daycare center, favorable environments for the child's development. However, not all mothers recognized their homes as a conducive environment for their child's learning:

It's better to bring him to the daycare center, right? Because here he's also learning, at home he isn't. (M2)

When asked about the performance of the health professionals in the daycare center, some mothers consider this action to be important for monitoring the child's health and recognize that these sectors should work together to care for the child:

I don't think it would change anything if the health professionals come to the daycare center to do the monitoring, I think it's the same way. (M2)

I believe that the daycare center and the unit can walk together (...) and if the professionals [of the FHU] were here [daycare center] it would be easier, for sure. (M3)

I think they don't work together, it's the first time that I see them here, and I don't see much difference. (M4)

(...) I'd find it very useful that the daycare center and the health unit worked together, because the doctor would be closer to him, right?! Knowing if he's in good health, or if he's not well (...). (M6)

DISCUSSION

The mothers participating in the study recognize the importance of the daycare center in promoting the development of children and the inclusion of health professionals in the surveillance of child growth and development in this scenario, as established by the PSE. However, the importance they give to monitoring the child's health in childcare consultations is diverse.

The childcare consultation carried out at the FHS brought about great impacts on child care,¹⁸ as this health care level is a favorable scenario for changes in the population's health conditions. The FHS is responsible for significantly reducing child mortality, as well as for improving nutritional status and increasing vaccination coverage for children.¹⁸

Thus, monitoring in the FHS and in the daycare center is fundamental for the full development of children, and this is already being recognized worldwide, when it was stated that investment in early childhood will influence the future of a Nation, as children who reach their development potential will be more successful, bringing a new path to the world economy,¹⁹ and this includes the insertion of children in early childhood education institutions.

Despite the relevance of promoting CDS, the mothers' reports suggest weakness in monitoring the growth and development in the health unit since, according to them, it has not been carried out satisfactorily, the human resources in the service are limited, and the health actions are focused on the biomedical care model that endures in society. This reality is opposed to the care aimed at disease prevention and health promotion advocated in PHC.²⁰ Thus, it is perceived that these weaknesses can influence the mother's decision to seek the health unit in order to monitor the care of her child.

Given this context, it is extremely important that the mothers are sensitized to continue consultations in the FHU, even after the child's insertion in the daycare center and in view of the weaknesses found in the health units. This is because for the child to be fully assisted, it is necessary to promote CDS by health professionals, in the school environment and/or in the health services.

Regarding this, an integrative review that sought to analyze the role of Nursing in promoting the health of children attending daycare centers highlighted that one of the reasons cited by the parents for not taking their children to health units for childcare consultation was lack of time. Therefore, the performance of health professionals in daycare centers has the potential to raise the awareness of those responsible for the children, by emphasizing the importance of child follow-up and the promotion of healthy growth.¹²

Another aspect that draws the attention in a mother's report is that the child's full-time permanence in the CREI was a justification for not performing the child's monitoring in the FHS, as well as the absence of the physician, demonstrating fragility in the bond with the health team and integrality in child health care in the context of PHC.²¹

Corroborating this finding, a study that investigated the mothers' perception of the continuity of child care in PHC highlights the compromise of this attribute, since some mothers seek the health service only when they need to,²² and not routinely to monitor the child in childcare consultation.

The search for the treatment of diseases already installed is still a reality in the FHS, indicating that there is an important demand for curative assistance, which is rooted not only in health professionals, but also in the users' culture. Although the FHS principles are based on the principle of health promotion and disease prevention, in addition to treatment, the population was not prepared for such a care model, and this weakens the preventive practices that must be prioritized within the scope of Primary Care.²³

As a result, the child's health becomes vulnerable because there is no therapeutic relationship among the actors involved, and also when the interventions are based on complaint-conduct.²¹ In this context, it is essential that health professionals pay attention to the comprehensive care of the child, in order to meet the real needs of the child population and the care model proposed by the PSE. It is also noteworthy that the mothers linked the child follow-up consultation only to the figure of the physician, while the recommended by the Ministry of Health is the execution of this consultation, both by the nurse and by the physician.¹¹ These findings are similar to those of a study in which the mothers state that childcare should be the responsibility of the physician, especially the pediatrician.²⁴

Another study with FHS nurses shows that the mothers do not seem to value childcare consultations, and focus child care on medical professionals, with predominantly curative actions,²⁵ corroborating the findings of this study, which indicate that the search for health services mostly occurs when the child is ill.

In contrast to these data, other mothers demonstrated that they understood the importance of the childcare consultation to monitor the child's growth and development, as well as to maintain the child's health. In line with this, a study found that maternal knowledge about the importance of child development surveillance in the child's health/disease process is one of the factors that encourages the mothers to seek the health unit to monitor the child.²⁶

In relation to the health actions carried out by the FHS professionals in the daycare center, it was noticed that these take place in a punctual manner, without a scheduled routine, usually including the analysis of the vaccination calendar and its update, when necessary, and teaching tooth brushing, being compatible with a study that identified specific situations in health actions at the request of daycare professionals.²⁷

The mothers of this study highlighted the need to articulate health and education actions, in other words, to implement intersectoriality, which is the articulation of sectors and the exchange of knowledge with the aim of integrating conduct. However, this initiative is still little practiced, since dialog between these sectors is not equitable, as there is fragmentation of actions and predominance of sectorized and biomedical conducts.²⁸

The low involvement of education professionals in the actions of the PSE is also noteworthy, this primarily becoming responsibility of the health teams, with some auxiliary participation of the educators in lectures and clinical evaluations, reinforcing the biomedical and fragmented health model.^28,29

Although the PSE has as a principle the integration and articulation between the FHS and the CREIs in its area of coverage,¹⁰ it is necessary to raise awareness and train all the actors involved about this program, for a better implementation of the PSE proposal and consequent effective and comprehensive care to children and their families. Despite the relevance of the above, a study showed a low number of CREIs that had systematic monitoring by FHU professionals, despite the high prevalence of children with impaired child development,²⁷ confirming the need for joint activities.

In this way, the important role of the PSE is reinforced to strengthen the articulation between the daycare center and the Health Unit in CDS, by providing actions for the promotion of integral development and the confrontation of vulnerability. For this, it is necessary to assess children's health, so that they can be referred to more specific monitoring by health professionals, when necessary, as well as the incentive for mothers/caregivers to take their children to the FHU at least once a year¹⁰ and whenever necessary.

Thus, it is understood that health actions in the field of education go beyond hygienist activities, as it is possible to carry out and qualify CDS, considering that the PSE is a program with an excellent opportunity to promote healthy child development and to prevent health problems.

Furthermore, the mothers recognize the daycare center as a favorable environment for the promotion of children's development, as well as they perceive positive changes in their behavior after their insertion in the daycare center, similarly to a study that highlighted that, for some mothers, the daycare center is the best environment for the care of their children, to the detriment of alternative care by relatives and nannies, and point out the quality of the daycare center as a decisive factor for such a choice. In addition to that, it is the safest environment, promotes greater socialization of the child, and provides greater incentives for child development.⁷

The CREIs have become a privileged space for the promotion of the main necessary bonds and stimuli and for monitoring the child's growth and development. Therefore, daycare professionals must be alert to the promotion of child development. For this, FHS professionals must promote care actions in the daycare center based on comprehensiveness; among them, conducting educational health practices for caregivers and daycare center managers, parents and guardians, especially for children identified with some alteration and/or risks in growth⁵ and development.

It is also fundamental to listen attentively to the mothers/caregivers, given that they have greater capacity to identify the advances and/or possible delays presented by the child.³⁰

Early childhood has shown itself to be a window of opportunity that promises great changes regarding the return invested in policies and practices that aim to optimize child development and help these children to be successful in life.³¹ Children who do not have an adequate physical, mental, cognitive and social-emotional stimulus are prone to negative health consequences, failures at school, delinquent behaviors and unemployment.

In addition, the family's socioeconomic situation brings about vulnerability to the children, conferring them a high risk of developmental delay or academic failure,³² a problem that was identified in the sociodemographic data of the participants in this study.

On the other hand, the early insertion of vulnerable children in educational institutions that promote neuropsychomotor development, associated with health care, high-quality nutrition and social support services promote important future gains in academic and professional development during adulthood.³²

CONCLUSION AND IMPLICATIONS FOR THE PRACTICE

The results of this study indicate that the mothers of children enrolled in a daycare center perceive that child development surveillance is weakened in this space, since the FHS professionals develop only punctual and hygienist actions, which differs from what is recommended by the PSE. However, they recognize a qualitative jump in the development of their children after their insertion in this educational space.

Thus, for the CREIs to establish themselves as spaces that promote child growth and development, it is necessary that they offer actions jointly with the FHS. For this, training of health and education professionals for child development surveillance and PSE guidelines is recommended, so that intersectoral actions are implemented with a view to comprehensive health care for children, given that countless children with different risk factors for development remain most of the time in daycare centers and, therefore, need to be monitored and stimulated.

The main limitation was related to the research being carried out in a single daycare center in which the children enrolled in the CREI were over two years old, which made it difficult to include mothers of younger children. However, it was possible to give the mothers visibility about their understanding of their children's development and their health care in the context of the daycare center and the family health unit.

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Edited by

• ASSOCIATED EDITOR
  Beatriz Rosana Gonçalves de Oliveira Toso

Publication Dates

• Publication in this collection
  19 May 2021
• Date of issue
  2021

History

• Received
  29 Oct 2020
• Accepted
  17 Mar 2021